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Mental Status Screening Examination
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See Chapter 15 for a complete discussion.
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During the history and physical examination, the clinician is evaluating the patient’s mental status. In addition, screening tests like the SLUMS, Mini-Cog, and Mini-Mental State Examination can be used. These are described in Chapter 15. The components of the mental status examination of most interest for neurologic disease are the level of consciousness, memory, and language.
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Cranial Nerve (CN) Exam
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The 12 pairs of CN emerge from the brain and pass through foramina in the skull base. They are designated by Roman numerals I to XII in relation to their position from forebrain to brainstem. The physical examination of several of the CN is contained in the discussion of the head and neck in Chapter 7.
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Olfactory nerve (CN I)
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The olfactory mucosa lining the upper third of the nasal septum and the superior nasal concha contains the receptors and ganglion cells. Their fibers converge into approximately 20 branches that pierce the cribriform plate of the ethmoid bone and consolidate to form the olfactory tract.
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Evaluate the nasal passages for patency. With the eyes closed, test each nostril while the other is occluded, with familiar odors, such as coffee, cloves, or peppermint.
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The optic nerve is actually a tract of the CNS, not a true cranial nerve. It carries afferent impulses from the retina to the Edinger–Westphal nucleus and the visual cortex in the occipital lobes.
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Tests for gross visual fields defects
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Confrontation Methods: Use a combination of the following tests to detect visual field defects [Kerr NM, Chew SS, Eady EK, Gamble GD, Danesh-Meyer HV. Diagnostic accuracy of confrontation visual field tests. Neurology. 2010;74:1184–1190]. Finger, face, and hand confrontation readily detect temporal field cuts. To detect nasal field cuts, you must test each eye independently.
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Fingers are presented simultaneously in one quadrant on either side of the midline, testing all quadrants sequentially. The gaze is kept straight ahead at a the examiners nose allowing the examiner to use their visual field as a control. The patient is asked to sum the number of fingers seen. Because it is difficult to differentiate three fingers from four, it is best to use one, two, or five fingers. This testing tells whether there is an absolute defect in one quadrant. You can increase the sensitivity by decreasing the presentation time and increasing the distance from the patient.
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Face and hand confrontation
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The patient looks at the examiner’s face first with one eye and then the other, and is asked if the face is clear with each eye and if the images are the same. A lack of clarity in one eye or a difference between the eyes suggests a field defect. With hand confrontation, the patient fixes on the examiner’s nose and the examiners hands are held on either side of the vertical midline first above then below the plane of gaze. The patient is asked if the hands appear the same. A cloudy or a faded-color appearing hand represents a relative and subtle defect along the vertical plane.
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This test is traditionally done with red caps of mydriatic bottles. (1) Color comparison about the vertical midline is performed as hand comparison above. This is a very sensitive test for relative hemianopic defects. (2) For central scotoma testing of each eye, the subject is asked to cover the opposite eye and fix their gaze on one red cap just lateral to the axis of gaze, whereas the other is held in their nasal visual field. Ask which cap is redder or brighter. If the peripheral cap is brighter when in fact they are the same color, there is a central scotoma. Do not hold the peripheral cap in the temporal field as a cecocentral defect may confound interpretation; likewise, you might place the cap in the patient’s blind spot.
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Kinetic boundary test
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Have the patient cover the left eye (Fig. 14-1). Face the patient approximately 1 m (40 in) at the same eye level. Ask the patient to fix constantly on your left eye. Cover your right eye fixing your left gaze on the patient’s unmasked eye. Hold your left hand off to the side in the midplane between your faces. With a flicking finger or penlight for a target, bring it slowly toward the midline between you (Fig. 14-1). Ask the patient to indicate when the target first appears and compare that with your own perception. Also, test vertical and oblique runs. Test the nasal field with your right hand. Test the second eye similarly. This technique is more time consuming and less sensitive and specific than the first three; it is not recommended [Pandit RJ, Gales K, Griffiths PG. Effectiveness of testing visual fields by confrontation. Lancet. 2001;358:1339–1340].
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Techniques for uncooperative patients
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In obtunded adults, watch for eye movements to novel targets or a blink in response to a threat by an abrupt movement toward the head in each field. If the movement pushes air over the cornea, it will stimulate a corneal reflex that can be misinterpreted as a visual response.
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Oculomotor (CN III), trochlear (CN IV), and abducens nerves (CN VI)
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CN III is the motor nerve to five extrinsic eye muscles: the levator palpebrae superioris, medial rectus, superior rectus, inferior rectus, and inferior oblique. Its nucleus in the posterior midbrain has a locus for each muscle. CN IV innervates the superior oblique muscle. The CN VI innervates the lateral rectus. These cranial nerves are tested together because they work together to produce the eye movements.
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The optical axis of the globe passes from the midpoint of the cornea to the fovea. The globe is suspended at the orbital rim by a fascia that is continuous with the orbital septum and orbital periosteum. This method of floating suspension allows the globe to rotate about three axes intersecting perpendicularly at the center of rotation. The gaze can therefore be directed to any anterior location combining any of these planes. Rotation about the vertical axis through the equatorial plane of the globe permits abduction and adduction; rotation about the horizontal axis through the equator produces elevation and depression; rotation about the optic axis allows intorsion (toward the nose) and extorsion (away from the nose).
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Six muscles rotate the globe around the three axes. The four recti originate in a fibrous ring around the optic foramen in the orbital apex (Fig. 14-2); these muscles insert slightly anterior to the global equator, spaced 90 degrees apart; the superior and inferior recti attach to the superior and inferior meridian, whereas the lateral (external) and medial (internal) recti are opposed on the horizontal meridians. The superior oblique muscle originates above the four recti at the optic foramen and then runs anteriorly and medially to the trochlea, a fibrous pulley in the medial side of the anterior orbit, from which it runs laterally and posteriorly under the superior rectus to insert behind the equator in the upper lateral quadrant of the posterior globe. Its physiologic point of action is at the pulley. The inferior oblique muscle originates anteriorly near the medial lacrimal groove, passes posteriorly and laterally between the inferior rectus and the orbital floor to its insertion in the posterior lower lateral quadrant.
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In the primary position, the globes are suspended with their optic axes horizontal in the sagittal plane. Because the rectus muscles pull toward the orbital apex, the lateral recti are longer than the medial recti. The superior and inferior recti do not pull exactly in the direction of the optic axis in the primary position (Fig. 14-3A). Study Figure 14-3 to visualize the movement imparted by each of the six muscles starting from the primary position. Contraction of the medial rectus, with relaxation of the opposed lateral rectus, produces adduction; contraction of the lateral rectus and relaxation of the medial rectus results in abduction. Contraction of the superior rectus elevates and intorts the globe because the angular pull produces some rotation about the optic axis. Similarly, the inferior rectus causes depression and extorsion. The superior oblique depresses and intorts, assisting the depression while countering the extorsion of the inferior rectus. The inferior oblique assists the superior rectus in elevation, whereas its extorsion counters the intorting action of the superior rectus. Deviation from the primary position changes the relative effects of various muscles. When the eye is abducted (Fig. 14-3B) so that the pull of the superior and inferior recti coincides with the optic axis, the recti produce pure elevation and depression, respectively. Similarly, adduction can attain a position where the oblique muscles pull along the equator to produce pure elevation and depression without intorsion or extorsion (Fig. 14-3C). Convergence is accomplished by contraction of the two medial recti.
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Testing extraocular movements
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Ask the patient to indicate if they see double as you test the six cardinal positions of gaze. Have the patient follow your finger to the right, right and up, right and down, to the left, left and up, left and down, and then return to the primary position (Fig. 14-4). When testing horizontally acting muscles, hold the stimulus with the long dimension vertically; for testing vertically acting muscles, hold it horizontally. This allows the patient to more easily see a doubled image. Test convergence by holding the target in the midline and at eye level, approximately 50 cm (20 in.) from the face, gradually moving the target toward the bridge of the nose; note the near point at which convergence fails, normally, 50 to 75 mm (2–3 in.). Finally, test for saccades by having the patient follow your finger as it moves both right–left and up–down. Normally, the eyes track a moving object smoothly; jerky eye movements are saccadic indicating repetitive loss of fixation and refixation. The eyes only move smoothly when tracking a target; this cannot be done consciously.
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Trigeminal nerve (CN V)
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CN V is the largest CN; it has three divisions. Its sensory root supplies the superficial and deep structures of the face and the deep structures of the head; its motor root innervates the muscles of mastication. The first division, or ophthalmic branch (CN V1), contains sensory fibers from the cornea, ciliary body, conjunctiva, nasal cavity and sinuses, and skin of the eyebrows, forehead, and nose. The second division, or maxillary branch (CN V2), contains sensory fibers from the skin on the side of the nose, the upper and lower eyelids, the palate, and maxillary gums. The third division, or mandibular branch (CN V3) is a mixed nerve with sensory and motor nerves: its sensory fibers are from the temporal region, the external ears, lower lip, lower face, mucosa of anterior two-thirds of the tongue, mandibular gums, and teeth. The motor root supplies the muscles of mastication: masseter, temporalis, and internal and external pterygoid.
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Testing the trigeminal nerve
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Motor Division: Inspect for muscle wasting in the temporal region, jaw tremor and trismus (spasm of the masticatory muscles). Palpate the temporal and masseter muscles comparing the muscle bulk and tension on the two sides while the patient clenches the teeth (Fig. 14-5A). If there is malalignment of the incisors when the mouth is opened, paralysis of the pterygoid muscle on the weak side is indicated. Sensory Division: With the eyes closed, test light touch, pain and temperature in each division comparing the two sides (Fig. 14-5B). The jaw jerk tests both the motor and sensory components of the trigeminal nerve. Test the corneal reflex by having the patient look upward while you gently touch the cornea (not the sclera) with a small shred of sterile gauze; this normally induces blinking. The corneal reflex is a bilateral reflex testing the fifth and seventh CN on the side stimulated and the seventh consensually.
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Facial nerve (CN VII)
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The facial nerve contains motor, autonomic, and sensory fibers. It supplies motor fibers to the muscles of the scalp, face, and auricula as well as to the buccinator, platysma, stapedius, stylohyoideus, and the posterior belly of the digastricus. Autonomic motor fibers in the chorda tympani nerve, a branch of CN VII, supply the submandibular and sublingual salivary glands. CN VII carries sensation from the ear canal and behind the ear and taste on the anterior two-thirds of the tongue.
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Testing the facial nerve
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Motor: Inspect the face in repose for paralysis or spasm. Have the patient perform the tasks below to detect asymmetry indicating unilateral paralysis and to determine whether the cause is an LMN or an UMN lesion: (1) inspect the face in repose noting the palpebral fissures, nasolabial folds and corners of the mouth; (2) elevate the eyebrows and wrinkle the forehead or have them look up and inspect the forehead wrinkles; (3) frown; (4) tightly close the eyes; (5) show the teeth; (6) whistle and puff the cheeks; and (7) smile. Sensory: Test taste on the anterior two-thirds of the tongue with sugar, vinegar (dilute acetic acid), quinine, and table salt. Write the words sweet, sour, bitter, and salty on a piece of paper and have the patient identify the sensation. Holding the tongue in gauze, touch the anterior two-thirds successively on one side then the other with an applicator saturated with the test substance. Remember, sweet receptors are located on the tip of the tongue. Get the patient’s response before testing the other side. Have the patient rinse the mouth with water between tests.
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Acoustic nerve (CN VIII)
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The eighth nerve is a relatively short trunk consisting of the cochlear and vestibular sensory nerves. They are morphologically and functionally distinct. The cochlear nerve supplies the organ of Corti, whereas the vestibular nerve furnishes sensory endings for the semicircular ducts.
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Glossopharyngeal nerve (CN IX)
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CN IX contains sensory, motor, and autonomic fibers. The sensory nerves are for pain, touch, and temperature from the mucosa of the pharynx, fauces, and palatine tonsil; and it is the taste nerve from the posterior third of the tongue. Somatic motor fibers travel through both the glossopharyngeal and vagus to innervate the pharyngeal muscles.
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Testing the glossopharyngeal nerve
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This is tested with the vagus nerve, below.
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The vagus carries motor, sensory, and autonomic fibers to and from the neck, thorax, and abdomen. It exits the skull in the jugular fossa. Its cervical branches are the pharyngeal, superior laryngeal, recurrent laryngeal, and superior cardiac nerves. The thoracic branches are the inferior cardiac, anterior and posterior bronchial, and esophageal nerves. The major abdominal branches are the gastric and hepatic nerves, and the celiac and superior mesenteric ganglia.
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Testing glossopharyngeal and vagus nerves
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Listen for voice quality and normal variations of tone. Pharynx: While inspecting the pharynx, have the patient say “ah,” noting elevation of the uvula. Note whether the faucial pillars converge equally. Test the gag reflex by touching the back of the tongue with a tongue blade. Test the pharyngeal mucosa for areas of anesthesia by touching with an applicator. Larynx: Watch the laryngeal contours in the neck to see if they rise with swallowing (Fig. 14-5D). Have the patient swallow water observing for coughing or reflux into the posterior nose. Examination of the vocal cords is described in Chapter 7 on Examination of the Larynx.
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Accessory nerve (CN XI)
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The accessory nerve is the motor nerve to the trapezius and sternocleidomastoid muscles.
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Testing the accessory nerve
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Palpate the upper borders of the trapezii while the patient raises his shoulders against resistance. Look for scapular “winging” as the patient leans against a wall with palms and arms extended. Test the strength and the bulk of the sternocleidomastoid by having the patient turn his head to one side then attempt to bring his chin back to the midline against resistance (Fig. 14-5E).
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Hypoglossal nerve (CN XII)
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The hypoglossal is the motor nerve to the tongue.
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Testing the hypoglossal nerve
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Inspection for fasciculations and wasting is done with the tongue at rest in the floor of the mouth. Fasciculations may be normal when the muscles contract to protrude the tongue. When one side is paralyzed, the tongue protruded tongue deviates toward the weak side (Fig. 14-5F). Test muscle strength by having the patient push the tongue against the cheek while your hand resists from the outside. Test lingual speech by having the patient repeat “La, La, La”.
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K, L, M test for dysarthria
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To parse cranial nerve deficits causing dysarthria, ask your patient to say: “Ka, Ka, Ka” (gutturals, CN IX and CN X); “La, La, La” (linguals, CN XII); and “Me, Me, Me” (labials, CN VII).
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Normal motor function requires that the skeleton, muscles, and motor nerves (pyramidal and extrapyramidal) are intact. Assessing muscle movements requires joint motion; hence the orthopedic, rheumatologic, and neurologic examinations are interdependent.
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Inspecting for Muscle Wasting
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Evaluation for wasting is done by comparing the muscle masses side to side and the relative masses in different regions.
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Evaluating Muscle Tone
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With the patient relaxed, assess muscle tone by resistance to passive range of motion. You may need to divert the patient’s attention to relax the muscles. Gently rocking or lifting a limb and letting it fall reveals the tone. When the patient sits on the exam table the freedom of dangling leg swing indicates their tone.
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Testing Muscle Strength
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Have the patient actively move the joint through its range of motion. Then have the patient try moving against resistance while you palpate the contracting muscle (Fig. 14-6). If the limb cannot move against gravity, position it to move unaffected by gravity. An arbitrary scale is used for grading muscle strength.
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Grading muscle strength (Oxford Scale)
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Grade 0—No muscle movement.
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Grade 1—Muscle movement without joint motion.
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Grade 2—Moves with gravity eliminated.
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Grade 3—Moves against gravity but not resistance.
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Grade 4—Moves against gravity and light resistance.
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Lower extremity muscle strength usually exceeds the examiner’s arm strength, so mild leg weakness is easily missed with resisted motion. Therefore, the following tests are useful. (1) Watch the patient get up after sitting on the floor. Use of both arms and raising the buttocks first by working the hands on the floor toward the feet and then up the legs, indicates proximal muscle weakness (Gowers sign). (2) Ask the sitting patient to stand without using their arms for assistance; if they do this easily, see if it can be done one leg at a time using the hands only for balance. (3) Have the patient hop on the balls of the feet, then on each foot individually. Normally, the heel will not strike the ground. Having the patient hop on a piece of paper will accentuate the sound of the heel strike (creating a “gallop” rhythm), indicating gastrocnemius and soleus muscle weakness.
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Examination of reflexes
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In the screening examination, the clinician usually tests a few reflex arcs, representative of various levels in the spinal cord and brainstem. A normal reflex confirms the integrity of each element in the reflex arc and proper function of the descending motor tracts. When an abnormality is encountered, lesions can be localized by mapping the normal and abnormal reflexes to their spinal cord and brainstem levels.
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These are tested during CN examination. The CN innervations of the afferent and efferent limbs are shown in parentheses.
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Direct pupillary reaction to light
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The iris constricts when bright light is shone on the retina (afferent CN II; efferent ipsilateral CN III).
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Consensual pupillary reaction to light
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Light stimulation of one retina produces constriction of the contralateral pupil (afferent CN II; efferent contralateral CN III).
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Pinching the skin on the back of the neck causes the pupils to dilatate (afferent cervical somatic nerves; efferent cervical sympathetic chain).
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Touching the cornea causes blinking of the eyelids (afferent CN V; efferent CN VII).
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When the mouth is partially open and the muscles relaxed, tapping the chin closes the jaw. The reflex center is in the mid-pons (afferent CN V; efferent CN V).
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Gagging occurs when the pharynx is stroked. The reflex center is in the medulla (afferent CN IX, -X; efferent CN IX, -X).
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The Muscle Stretch Reflexes
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Muscle stretch reflexes are often misnamed “tendon” reflexes. The muscle is stretched by a brisk tap on its taut tendon of insertion. The muscle stretch reflex is a simple reflex arc containing a muscle cell, a sensory, and a motor neuron (Fig. 14-7). A diminished or absent reflex indicates an interrupted reflex arc. When the descending motor pathway (the pyramidal tract) in the spinal cord is injured above the level of the reflex arc, normal cortical inhibition is lost, producing a hyperactive or spastic reflex. General principles for eliciting muscle stretch reflexes: The limb should be relaxed. Identify the tendon of the muscle to be tested. Position the limb so that the muscle is slightly stretched. Strike a brisk blow on the tendon with the finger or reflex hammer; if the tendon cannot be struck directly, place your thumb on the tendon and strike your thumb. If no reflex is present, reinforcement can be used: have the patient concentrate on a voluntary act such as pulling on interlocked fingers or clenching the fists while you test the reflex.
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There is considerable variability in normal reflexes, from absent to brisk. Significant asymmetry between right and left at the same level is abnormal. Clonus, the sustained repetitive maintenance of the reflex arc with tonic stretch of the muscle is always abnormal. A four-point scale, denoted by numbers or pluses, is commonly used to grade the reflex response.
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1, + Detectable only with reinforcement
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3, + + + Brisk with at most a few beats of clonus
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4, + + + + Sustained clonus
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The reflexes below are listed by descending level of the reflex center in the spinal cord. The peripheral nerves carrying the afferent and efferent signal are listed in parentheses.
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Reflex center at C5 to T1: pectoralis reflex (medial and lateral anterior thoracic nerves)
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Support the arm in 10 degrees of elevation at 90 degrees of abduction (Fig. 14-8A). Place the fingers of your left hand on the patient’s shoulder with your thumb extended downward pressing firmly on the tendon of the pectoralis major. Strike a blow directed upward toward the axilla. The muscle contraction can be seen or felt.
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Reflex center at C5 to C6: biceps reflex (musculocutaneous nerve)
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Place the elbow at 90 degrees of flexion with the arm slightly pronated. Grasp the elbow with your left hand so that the fingers are behind and your thumb presses the biceps tendon (Fig. 14-8B). Strike a series of blows on your thumb varying your thumb pressure with each blow until the most satisfactory response is obtained. The normal reflex is elbow flexion.
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Reflex center at C5 to C6: brachioradialis reflex (radial nerve)
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Hold the patient’s wrist with your left hand with the forearm relaxed in pronation (Fig. 14-8C). With a vertical stroke, tap the forearm directly, just above the radial styloid process. The normal response is elbow flexion and forearm supination.
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Reflex center at C6 to C7: pronator reflex (median nerve)
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Hold the patient’s hand vertically so the wrist is suspended (Fig. 14-8D). From the medial side, strike the distal end of the radius directly with a horizontal blow. The normal response is pronation of the forearm. Alternatively strike the distal end of the ulna directly with a blow mediad.
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Reflex center at C7 to C8: triceps reflex (radial nerve)
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Hold the patient’s arm at 90 degrees abduction and elevation, allowing the relaxed forearm to dangle with the elbow at 90 degrees flexion (Fig. 14-8E). Tap the triceps tendon just above the olecranon process. The normal response is elbow extension. Alternatively, have the patient flex both elbows, bringing the arms parallel across the chest (Fig. 14-8E). Have each hand grasp the other forearm. Reinforcement can be obtained by having the patient grasp harder and extending the elbow slightly.
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Reflex center at T8 to T9: upper abdominal muscle reflex
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Tap the muscles directly near their insertions on the costal margins and xiphoid process (Fig. 14-9A).
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Reflex center at T9 to T10: middle abdominal muscle reflex
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Stimulate the muscles of the mid-abdomen by tapping an overlaid finger or doubled-tongue blades (Fig. 14-9B).
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Reflex center at T11 to T12: lower abdominal muscles
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Tap the muscle insertions directly, near the symphysis pubis (Fig. 14-9C).
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Reflex center at L2 to L4: quadriceps reflex (femoral nerve)
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Several methods are available. In each, a normal response is extension of the knee and contraction of the quadriceps can be palpated. Legs Dangling (Fig. 14-10A): Grasp the lower thigh with your left hand, then tap the patellar tendon. Sitting, Feet on the Floor (Fig. 14-10B): The patient sits on a chair or low bed with the toes curled in plantar flexion and knee slightly extended from a right angle. Tap the patellar tendon directly. Lying Supine (Three Methods): Method 1—With your hand under the popliteal fossa, lift the patient’s knee from the table. Tap the patellar tendon directly (Fig. 14-10C). Method 2—Grasp the patient’s foot, flexing the hip and knee, and rotate the knee outward and dorsiflex the foot. Tap the patellar tendon directly (Fig. 14-10D). Method 3—With the knee extended and the leg lying on the table and your index finger on the quadriceps tendon insertion, push the patella distally. Tap downward on the index finger (Fig. 14-10E). The muscle contraction pulls the patella proximally.
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Reflex center at L2 to L4: adductor reflex (obturator nerve)
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With the patient supine, place the limb in slight abduction (Fig. 14-11A). Directly tap the adductor magnus tendon just proximal to its insertion on the medial epicondyle of the femur. Normally, the thigh adducts. An absent quadriceps reflex and normal adductor reflex indicates a femoral nerve lesion.
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Reflex center at L4 to S2: hamstring reflex (sciatic nerve)
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Have the patient supine with hips and knees flexed at about 90 degrees and the thighs rotated slightly outward. Place your left hand under the popliteal fossa so the index finger compresses the medial hamstring tendon (a bundle of tendons from semitendinosus, semimembranosus, gracilis, sartorius) (Fig. 14-11B). Tap your finger. The normal response is flexion of the knee and contraction of the medial mass of hamstring muscles. Test the lateral hamstrings in a similar manner: with your finger compress the lateral hamstring tendon just proximal to the fibular head and tap your finger. The normal response is contraction of the lateral hamstring mass (biceps femoris) and flexion of the knee.
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Reflex center at L5 to S2: Achilles reflex (tibial nerve)
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Assess both the contraction and relaxation of the muscle. The normal response is contraction of the gastrocnemius and plantar flexion of the foot; delayed relaxation (hung-up reflex) is characteristic of hypothyroidism. Legs Dangling (Fig. 14-11C): With your left hand, grasp the patient’s foot and pull it into dorsiflexion to find the amount of Achilles stretch that produces the optimal response. Tap the tendon directly. Kneeling (Fig. 14-11C): Have the patient kneel with the feet hanging over the edge of a chair, table, or bed. With your left hand dorsiflexing the foot, tap the tendon directly. Supine (Fig. 14-11C): Partially flex the hip and knee while rotating the knee outward as far as comfort permits. With your left hand, grasp the foot and pull it into dorsiflexion, then tap the Achilles tendon directly.
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The Superficial (Skin) Reflexes
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These reflex arcs have receptors in the skin rather than in muscle fibers. Their adequate stimulus is stroking, scratching, or touching. If there is no response, a painful stimulus can be tried. The superficial reflexes are lost in pyramidal tract disease.
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Reflex center at T5 to T8: upper abdominal skin reflex
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Have the patient supine and relaxed, with the arms at the sides and knees slightly flexed. Stroke the skin over the lower thoracic cage from the midaxillary line toward the midline (Fig. 14-12A). Watch for ipsilateral contraction of the muscles in the epigastric abdominal wall. When the muscle contractions cannot be seen, look for umbilical deviation toward the stimulated side. In very obese persons, retract the umbilicus toward the opposite side to feel it pull toward the side of stimulation.
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Reflex center at T9 to T11: mid-abdominal skin reflex
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Stroke the skin from the flank toward the midline at the umbilical level.
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Reflex center at T11 to T12: lower abdominal skin reflex
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Stroke the skin from the iliac crests toward the midline of the hypogastrium.
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Reflex center at L1 to L2: cremasteric reflex
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In males, stroke the inner thigh from the inguinal crease downward (Fig. 14-12B). Normally, this causes cremaster contraction with prompt elevation of the testis on that side. A slow and irregular rise of the testis results from muscular contraction in the dartos tunic and is not the reflex response.
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Reflex center at L4 to S2: plantar reflex
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Grasp the patient’s ankle with your left hand. With a blunt point and moderate pressure, stroke the sole near its lateral border, from the heel toward the metatarsal heads, where the course should curve medially following the bases of the toes (Fig. 14-12D). For the blunt point, use a wooden-tip applicator, the end of a split wooden tongue blade, or the dull handle end on a reflex hammer. If no response is observed, a pin should be used as this is a nociceptive reflex. Normally, this produces plantar flexion of the toes and, often, the entire foot. With pyramidal tract disease some or all of four components of the reflex may be seen: great toe dorsiflexion, fanning of all toes, ankle dorsiflexion, and knee and thigh flexion. This is Babinski sign; it should be recorded as present or absent.
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Reflex center at S1 to S2: superficial anal reflex (anal wink)
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Stroke the perianal skin and the anal sphincters contract.
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Posture, Balance, and Coordination—The Cerebellar Examination
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Precise voluntary movement requires graded contraction of the agonist, or prime mover, with a corresponding graded relaxation of the antagonist about each joint. Other muscles act to fix the joint. The total integration of these movements, called coordination, is partially mediated through efferent and afferent cerebellar tracts. The vestibular apparatus and the cerebral cortex also participate. Maintenance of posture and balance requires sensory input from the joints, muscles, tendons, and vestibular system, and coordinated motor outputs mediated by the cerebral cortex and basal ganglia.
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Ask the patient to stand comfortably with the arms at the sides (Fig. 7-16). Observe the position of the feet. Normally, the feet will be just a few centimeters apart and the knees opposed. A wide stance suggests an accommodation to instability of stance. Next, have the patient put the feet together and observe for stability. Note swaying of the trunk or elevation of the arms to maintain balance. Now, have the patient close her eyes while observing for loss of balance. Be ready to support her should she lose her balance and reassure her you will protect her. Loss of balance during the test is the Romberg sign. If she remains stable, tell her you are going to push her gently to assess her stability. Gently push her laterally on each upper arm, forward on the upper back and, last, backward on the chest. With normal proprioception, vestibular function, and cerebellar and motor pathways she will remain stable throughout. After fair warning, with her eyes open, push more firmly on her chest to check for maximal stability.
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Testing for Diadochokinesia
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Coordinated movements require the ability to arrest one motion and initiate its opposite. Loss of this ability (dysdiadochokinesia) is characteristic of cerebellar disease. Many simple tests can be used to test for dysdiadochokinesis. Alternating Movements (Fig. 14-13) (1) Have the patient hold his forearms vertically and alternate pronation and supination in rapid succession. In cerebellar disease, the movements overshoot, undershoot, or are irregular and inaccurate; the motions may be slowed or incomplete in disease of the pyramidal tract. (2) Have the patient rapidly tap his fingers on the table, or close and open the fists. (3) Holding the arms at 90 degrees elevation and 0-degree abduction may show the affected arm deviating in abduction. (4) While the patient clenches his fist with elbow flexed and forearm pronated, grasp his fist from above and pull strongly attempting to extend his elbow against his resistance; suddenly release your grip and observe for rapid control of rebound (Stewart–Holmes Rebound Sign, Fig. 14-13). The examiner must guard against injury to the patient. With cerebellar disease, the forearm may rebound in several cycles of extension-flexion; the patient may strike himself if not guarded.
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Testing for Dyssynergia and Dysmetria
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Finger-to-Nose Test: With the eyes open, have the patient fully extend his elbow and, in a wide arc, rapidly bring the tip of the index finger to the tip of his nose (Fig. 14-13B). In cerebellar disease, this is attended by an action tremor. Attempting this with the eyes closed evaluates position sense in the shoulder and elbow. A variation is to have the patient make wide arcs with both arms to touch the tips of his index fingers in front of him. Heel-to-Shin Test: With the patient supine and the lower limbs resting in extension, ask the patient to raise one heel and place it on the opposite knee, then slide the heel down the shin (Fig. 14-13C). The foot should be dorsiflexed, and the motion should be performed slowly and accurately. In cerebellar disease, the arc of the heel to the knee is jerky and wavering, the knee is frequently overshot, and the slide down the shin is accompanied by an action tremor. With the eyes closed, the motions are inaccurate in posterior spinal column disease. Frequently, the heel slides off the shin, but action tremor is absent.
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Gait is influenced by the rate, rhythm, and character of the individual movements employed in walking. Before assessing the neurologic contribution to gait, painful and restrictive conditions of the joints, muscles, and other structures must be excluded. Observe the patient’s gait in a well-lighted hallway. Note the head, neck and trunk posture, swing of each arm, leg swing, width of stance, step size, and clearance of the toe from the floor. Be sure to observe all three phases of gait: touch down, which should occur with the lateral heel; stance, which should be centered; and push-off which should come off the great toe. Foot strikes are normally in a nearly straight line. Also, observe a turn for loss of balance or multiple small steps to get turned around. Next, have the patient walk away from you on the toes, observing from behind, turn and walk toward you on the heels observing from the front; note how far the heels and toes, respectively, are held off the ground. Examine wear on the patient’s shoes; abnormal wear patterns are a good clue to disorders of the foot and gait.
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Testing Past Pointing
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Have the patient sit facing you, pointing his forefingers toward you with his eyes closed (Fig. 7-15). Place your forefingers lightly under his and hold them there. Ask the patient to raise his arms and hands, and then return his fingers to yours. Normally, this maneuver can be performed accurately. Past pointing indicates either loss of positional sense or labyrinthine stimulation.
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Other tests of labyrinth function are described in Chapter 7.
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Ask the patient to write a sentence to inspect handwriting. Test his facility at buttoning and unbuttoning a coat or shirt. Have him pick up pins or thread a needle. Test his skill at cutting figures out of paper with scissors.
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A complete assessment of sensory modalities is not made during the routine physical examination. A history of diabetes, localized pain, numbness, or tingling, or the finding of motor deficits, calls for a detailed sensory examination.
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The patient must be lucid and have adequate attention to cooperate with the examination. The clinician must have a detailed knowledge of segmental and peripheral nerve distribution in the skin (refer to Figs. 14-14 and 14-15) and make a drawing of the distribution of sensory deficits. The diagram may be used for immediate comparison on retesting; abnormal sensory examinations should be repeated for consistency, progression or resolution. Disparities in examinations may indicate factitious findings.
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The detailed cranial nerve exam includes testing of the special senses and the cutaneous sensation of the head. For the remainder of the body, the distribution of sensibility for cutaneous pain, touch, pressure, position, and vibration should be evaluated. If a deficit in pain sensation is detected, temperature sensation must be tested. When an area of altered cutaneous sensibility is found, the borders should be marked with a skin pencil, and a diagram recorded in the patient’s record.
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Testing Superficial Pain—Sharp-Dull
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Sensibility to pain may be increased (hyperalgesia), normal, reduced (hypalgesia) or absent (analgesia). Have the patient close his eyes. The skin is stroked lightly with the point of a sterile pin and asked if the sensation is painful (Fig. 14-16A). Observe the patient’s facial expression for signs of discomfort. If there is doubt about the response, mix sharp and dull stimuli from the point and head of the pin. Compare side-to-side with the same degree of pressure; it is better if the patient reports differences than if you suggest them. In mapping deficit borders, slowly stimulate the skin from nonsensitive to sensitive skin, having the patient indicate where the sensation changes.
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Test for deep or protopathic pain by pressure on the nerve trunks, and tendons. For example, in the Abadie sign for tabes dorsalis, the normal pressure tenderness of the Achilles tendon is lost.
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Testing Temperature Sense
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When pain sense is impaired, test for temperature sensibility; the pathways are closely associated. Ask the patient to distinguish between warm and cold. With the eyes closed, touch the skin with glass tubes of hot and cold water. Alternatively, test cold perception with a cold tuning fork and warm perception by exhaling on the skin through your widespread lips.
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Testing Tactile Sense
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With the eyes closed, compare sensation right to left by stroking the skin with a shred of sterile gauze. Have the patient indicate when and where you touch him. If you suspect that he is using his eyes, make sham tests near but without touching the skin. Grade the results as hyperesthetic, normal, hypesthetic, or anesthetic.
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Testing Proprioception (Position Sense)
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With the patient’s eyes closed, grasp a finger on the sides (avoid grasping on the top and bottom or touching adjacent fingers because that provides touch cues). Extend or flex the finger at one joint and ask the patient to state its position (Fig. 14-16B). Similarly, test the position sensation in the metatarsophalangeal joint of the great toe. Normal young patients discriminate 1 to 2 degrees of movement in their distal finger joints and 3 to 5 degrees of the great toe. Test position sense in the leg or arm with the eyes closed. Place one limb in a position and ask the patient to place its counterpart in a symmetrical position.
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Testing Vibration Sense (Pallesthesia)
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Place the handle of a vibrating 128-Hz tuning fork over bony prominences, such as the radial styloid, the subcutaneous aspects of the tibiae, the ankle malleoli, or the great toe interphalangeal joint (Fig. 14-16C). Compare symmetrical points. When the patient indicates that the vibration of the fork has ceased, place the handle on your own wrist to detect any persistence of vibration. Make sham tests by setting the fork in vibration and unobtrusively stopping it with your finger before applying the handle to the patient.
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Testing Pressure Sense
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Standardized monofilaments are available to precisely check for protective pressure sensation. Anesthesia to a 10-g monofilament is a sensitive test for loss of protective sensation to pressure injury. All diabetics should be tested at least once a year with this technique [Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med. 1994;331:854–860]. Test the patient’s ability to discriminate objects of different weight in their palms. Test the ability to distinguish between pressures from the head of a pin and the tip of your finger. Press over the joints and subcutaneous aspects of bones for perception of pressure.
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Testing Higher Integrative Functions
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Simple sensory perception must be normal. With the eyes closed, test the ability to identify objects placed in the hands. Use coins, pencils, glass, wood, metal, cloth, and other familiar articles.
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Testing two-point discrimination
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Test the ability to distinguish the separation of two simultaneous pinpricks as the stimuli are moved farther apart (Fig. 14-16D). Find the distance at which two points rather than one are identified. Test and compare symmetric regions. The normal distance varies in different parts of the body, from 1 mm on the tongue, to 2 to 8 mm on the fingertips, 40 mm on the chest and forearm, and 75 mm on the upper thigh and upper arm.
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Testing graphesthesia
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Tell the patient you will write numerals or letters “right-side up” on the skin. Then, while their eyes are closed, ask the patient to identify figures 1 cm high traced with a blunt point on the distal pad of the index finger. The figures should be at least 2 cm high on other body parts.
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Testing Specific Peripheral Nerves
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Exclusion test for major nerve injury in the upper limb
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Normal sensibility to pinprick in the index and little fingertips excludes major injury to the median and ulnar nerves. Normal extension of the thumb and fingers excludes radial nerve injury (Fig. 14-17).
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Testing the median nerve
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Motor Function: Have the patient clasp the hands firmly together; the index finger cannot flex when the innervation of the flexor digitorum sublimis has been injured anywhere below the antecubital fossa (Ochsner Test, Fig. 14-18A). Thumb Flexion (Fig. 14-18B) Hold the patient’s first metacarpophalangeal joint with your thumb and index fingers so that the metacarpal bone is extended and ask the patient to bend the interphalangeal joint; failure indicates paralysis of the flexor pollicis longus, innervated by the volar interosseus that branches from the median nerve in the middle third of the forearm. Thumb Abduction Testing the abductor pollicis brevis, innervated exclusively by the median nerve, distinguishes median from low-level ulnar nerve paralysis: (1) Wartenberg Oriental Prayer Position (Fig. 14-18C). Have the patient extend and adduct the four fingers of each hand, with thumbs extended, then raise the two hands in front of the face so they are side by side in the same plane, with thumbs and index fingers touching tip to tip. Paralysis of the abductor pollicis brevis prevents full range of thumb abduction, so thumbs do not come together when index fingers touch. (2) Pen-Touching Test (Fig. 14-18D). Have the patient rest the supinated hand on a table holding the fingers flat. Ask the patient to raise his thumb in straight up off the table to touch a pen or pencil held horizontally above the thumb. Sensory Function: Test touch, two-pont, and sharp-dull on the thumb, index, middle, and fourth finger, and palm; compare right to left (Fig. 14-18E). Decreased or absent sensation indicates a lesion in the median nerve.
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Testing the ulnar nerve
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Motor Function: Weakness of finger adduction results from paralysis of the interosseus palmaris demonstrated by pulling a sheet of paper from between the patient’s extended and adducted fingers to assess the pressure exerted by the sides of the fingers (Fig. 14-19A). Paralysis of the adductor pollicis can be tested by asking the patient to grip each end of a folded paper between thumbs on top and index fingers underneath. Have the patient pull the hands apart while gripping the paper. The thumb with an inadequate adductor flexes at its interphalangeal joint from involuntary use of the flexor pollicis longus, innervated by the median nerve (Fig. 14-19B). With lesions at or below the elbow, test for paralysis of the flexor carpi ulnaris. Lay the supinated hand on the table holding all but the little finger flat against the table. Have the patient abduct the little finger maximally; if there is no paralysis, the tensed tendon may be seen or palpated at the wrist (Fig. 14-19C). Sensory Function: An area of anesthesia covers the ulnar digits and the corresponding region of the palm. A similar distribution occurs on the back of the hand. When the nerve lesion is at the wrist the anesthesia is only on the distal half of the little finger (Fig. 14-19D).
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Movements of specific muscles and nerves
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It is frequently desirable to identify the muscles and nerves involved in a movement deficit. The following is a compilation of the principal muscle movements, the muscles involved, and their innervation (in parentheses). This survey starts with CN and precedes distally identifying movements served by cervical, thoracic, lumbar, and sacral roots sequentially. The reader can trace an abnormal movement to the peripheral nerve and spinal root or a deficit can be predicted for each peripheral nerve or spinal segment.
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Eyebrow, elevation. Frontalis (CN VII from inferior pons).
Eyebrow, depression downward and inward, wrinkling of the forehead. Corrugator (CN VII from inferior pons).
Upper eyelid, elevations. Levator palpebrae superioris (CN III from upper midbrain).
Eyelids, closing, wrinkling of forehead, compression of lacrimal sac. Orbicularis oculi (CN VII from inferior pons).
*Eyeball, elevation and adduction. Superior rectus (CN III from upper midbrain).1*
*Ophthalmologic Interpretation of Muscle Action. The items marked with asterisks constitute the actions of the oculorotatory muscles, as assigned by the anatomists and some neurologists. Sharply divergent interpretations are furnished by the ophthalmologists on the basis of clinical findings. The direction of movement of the eyes is a result of the actions of synergists and antagonists producing six cardinal positions of gaze, corresponding to the six extraocular muscles. Paralysis of a single muscle results in the inability of the eye to attain its cardinal position, which, in four of the six muscles, does not correspond to the prediction of the anatomists.
*Eyeball, elevation and outward rotation. Inferior oblique (CN III from upper midbrain).
*Eyeball, depression and rotation downward and inward. Inferior rectus (CN III from upper midbrain).
*Eyeball, depression and rotation downward and outward. Superior oblique (CN IV from midbrain) or primary downward rotation, secondary inward (intorsion) rotation, and tertiary weak outward rotation.
*Eyeball, adduction. Medial rectus (CN III from upper midbrain).
*Eyeball, abduction. Lateral rectus (CN VI from inferior pons).
Pupil, constriction. Ciliary (CN III and parasympathetic from upper midbrain).
Lips, retraction. Zygomatic (CN VII from inferior pons).
Lips, protrusion. Orbicularis oris (CN VII from inferior pons).
Mouth, opening. Mylohyoid (CN V from pons), digastricus (CN VII from pons).
Mandible, elevation and retraction. Masseter and temporalis (CN V from mid-pons).
Mandible, elevation and protrusion. Pterygoid (CN V from mid-pons).
Pharynx, palatine elevation and pharyngeal constriction. Levator veli palatini and pharyngeal constrictor (CN IX and X from medulla).
Tongue, depression and protrusion. Genioglossus (CN XII from medulla).
Neck, rotation of the head. Sternocleidomastoid and trapezius (CN XI from medulla and upper cervical cord).
Neck, flexion. Rectus capitis anterior (C1 to C3).
Neck, extension, and rotation of the head. Splenius capitis et cervicis (C1 to C4).
Neck, lateral bending. Rectus capitis lateralis (C1 to C4 and suboccipital nerve).
Spine, flexion. Rectus abdominis (T8 to T12).
Spine, extension. Thoracic and lumbar intercostals (thoracic nerves from T2 to L1).
Spine, extension and rotation. Semispinalis (thoracic nerves from T2 to T12).
Spine, extension and lateral bending. Quadratus lumborum (lumbar plexus from T10 to L2).
Ribs, elevation and depression. Scaleni and intercostal (cervical and thoracic nerves from C4 to T12).
Ribs, elevation. Serratus posterior superior (from T1 to T4).
Diaphragm, elevation and depression. The diaphragmatic muscles (phrenic nerve from C3 to C5). Remember diaphragmatic innervation by the phrenic nerve with the rhyme, “C3, 4, and 5 to keep the man alive.”
Scapula, rotation and extension of neck. Upper trapezius (CN XI from C3 to C4).
Scapula, retraction with shoulder elevation. Middle and lower trapezius (CN XI from C3 to C4).
Scapula, elevation and retraction. Rhomboids (dorsal scapular nerve from C5).
Arm, elevation. Supraspinatus (suprascapular nerve from C5 to C6), upper trapezius (CN XI from C3 to C4).
Arm, elevation and rotation. Deltoid (axillary nerve from C5 to C6).
Arm, depression and adduction. Middle pectoralis major (anterior thoracic nerve from C5 to T1).
Arm, depression and medial rotation. Subscapularis (subscapular nerve from C5 to C7), teres major (thoracodorsal nerves from C5 to C7).
Arm, depression and lateral rotation. Infraspinatus (suprascapular nerve from C5 to C6).
Elbow, flexion. Biceps brachii, brachialis (musculocutaneous nerve from C5 to C6).
Elbow, extension. Triceps brachii (radial nerve from C7 to T1).
Elbow, supination. Biceps brachii (musculocutaneous nerve from C5 to C6), brachioradialis (radial nerve from C5 to C6).
Elbow, supination and elbow flexion. Brachioradialis (radial nerve from C5 to C6).
Elbow, pronation. Pronator teres (median nerve from C6 to C7).
Wrist, extension and adduction. Extensor carpi ulnaris (radial nerve from C7 to C8).
Wrist, extension and abduction of hand. Extensor carpi radialis longus (radial nerve from C6 to C7).
Wrist, extension of the hand. Extensor digitorum communis (radial nerve from C7 to C8).
Wrist, flexion and abduction. Flexor carpi radialis (median nerve from C7 to C8).
Wrist, flexion and adduction. Flexor carpi ulnaris (ulnar nerve from C7 to C8).
Thumb, adduction and opposition. Adductor pollicis longus (ulnar nerve C8 to T1).
Thumb, abduction and extension. Abductor pollicis longus and brevis (median and radial [and posterior interosseous nerves] from C7 to C8).
Thumb, extension of distal phalanx. Extensor pollicis longus (radial nerve from C7 to C8).
Thumb, extension of proximal phalanx. Extensor pollicis brevis (radial nerve from C7 to C8).
Thumb, flexion of distal phalanx. Flexor pollicis longus (median nerve from C7 to T1).
Thumb, flexion of proximal phalanx. Flexor pollicis longus and brevis (median nerve from C7 to T1).
Thumb, flexion and opposition. Opponens pollicis (median nerve from C8 to T1).
Fingers, flexion and adduction of little finger. Opponens digiti minimi (ulnar nerve from C8 to T1).
Fingers, adduction of four fingers. Palmar interossei (ulnar nerve from C8 to T1).
Fingers, abduction of four fingers. Dorsal interossei (ulnar nerve from C8 to T1).
Fingers, extension of hand. Extensor digitorum communis (radial nerve from C7 to C8).
Fingers, flexion of hand. Palmar interossei (interosseous nerves from C7 to T1), lumbricales (ulnar and median nerves from C7 to T1).
Fingers, extension of interphalangeal joints. Interossei palmaris and lumbricales (interosseous nerve; median and ulnar nerves from C7 to T1).
Fingers, flexion of the distal phalanges. Flexor digitorum profundus (median and ulnar nerves from C7 to T1).
Fingers, flexion of middle phalanges. Flexor digitorum sublimis (median nerve from C7 to T1).
Abdomen, compression with flexion of trunk. Rectus abdominis (lower thoracic nerves from T6 to L1).
Abdomen, flexion of abdominal wall obliquely. Obliquus abdominis externus (lower thoracic nerves from T6 to L1).
Hip, flexion. Iliacus (femoral nerve), psoas (L2 to L3), sartorius (femoral nerve from L2 to L3).
Hip, extension. Gluteus maximus (inferior gluteal nerve from L4 or S2), adductor magnus (sciatic nerve and obturator nerve from L5 to S2).
Hip, abduction. Gluteus medius (superior gluteal nerve from L4 to S1), gluteus maximus (inferior gluteal nerve from L4 to S2).
Hip, adduction. Adductor magnus (sciatic and obturator nerves from L5 to S2).
Hip, outward rotation. Gluteus maximus (inferior gluteal nerve from L4 to S2), obturator internus (branches from S1 to S3).
Hip, inward rotation. Psoas (branches from L2 to L3).
Knee, flexion. Biceps femoris, semitendinosus, semimembranosus, gastrocnemius (all through sciatic nerve from L5 to S2).
Knee, extension. Quadriceps femoris (femoral nerve from L2 to L4).
Ankle, plantar flexion. Gastrocnemius and soleus (tibial nerve from L5 to S2).
Ankle, dorsiflexion. Anterior tibial (deep peroneal nerve from L4 to S1).
Ankle, inversion. Posterior tibial (tibial nerve from L5 to S1).
Ankle, eversion. Peroneus longus (superficial peroneal nerve from L4 to S1).
Great toe, dorsiflexion. Extensor hallucis longus and brevis (superficial peroneal nerve from L4 to S1).